Type * Last Name * First Name * Date of Birth * Phone number * Today's Date * Reason for Visit

Family History

Father Father's age Father health history Other Mother Mother's Age Mother's health history Other Paternal Grandfather Paternal Grandfather's age Paternal Grandfather's health history Other Paternal Grandmother Paternal Grandmother's age Paternal Grandmother's health history Other Maternal Grandfather Maternal Grandfather's age Maternal Grandfather's health history Other Maternal Grandmother Maternal Grandmother's age Maternal Grandmother's health history Other Brother(s) Brother's health history Other Sister(s) Sister's health history Other Children Children health history Other

Social History

Occupation Marital Status Do you smoke or chew tobacco? Packs/Day (current or past smoker) If past smoker, # years quit Do you drink alcohol? If yes, check all that apply If yes, # drinks/week Any Environmental Allergies ** Any drug allergies? ** Please list any current medications including dosages *

Hospitalizations or Surgeries

Reason Date Reason Date

Medical History

Medical History **

Thank you for completing our electronic Patient Health History form. We look forward to meeting you!

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